DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Elevated creatinine.
HISTORY OF PRESENT ILLNESS: This is a very pleasant (XX)-year-old female who was admitted with coffee-ground emesis and is showing black tarry stools and anemia. The patient was also admitted with a blood pressure of 178/98, tachycardia, and fever. The patient’s creatinine was found to be elevated at 2.3. We are asked to assist with her care. Unfortunately, the patient is demented and cannot give any history at this time. Her baseline mental status is unknown, but at this time, she does not respond to questions. Old records from 10 days ago show that her creatinine was 2.1 at that time. We have looked as far back as three years ago, which shows that her creatinine was 1.9 at that time.
PAST MEDICAL HISTORY: Apparently, from the chart, dementia; degenerative joint disease; anemia; dysphagia; and status post cesarean section.
MEDICATIONS: Senokot, Actonel, Oxytrol, Seroquel, Lexapro, omeprazole, vitamin D, and Os-Cal.
ALLERGIES: NKDA.
FAMILY HISTORY: Unknown.
SOCIAL HISTORY: The patient apparently does not use tobacco or alcohol.
REVIEW OF SYSTEMS: Unobtainable.
PHYSICAL EXAMINATION:
VITAL SIGNS: The patient’s blood pressure has improved to 168/74, pulse 94, and respiratory rate 18.
GENERAL: The patient is sleepy, not answering questions, and is in no distress.
HEENT: Pupils are reactive, symmetric. Oropharynx: Difficult to examine. Appears to be moist.
NECK: No JVD or lymphadenopathy.
HEART: Regular rate and rhythm.
ABDOMEN: Soft. Positive bowel sounds. No guarding or rigidity. No grimacing.
EXTREMITIES: No clubbing, cyanosis or edema.
LABORATORY DATA: Hemoglobin today has dropped to 8. The patient is being seen by Dr. Jane Doe. Her creatinine was stable at 2.3. Amylase and lipase are negative. Urinalysis demonstrates 1+ albumin and specific gravity of 1.015, otherwise within normal limits.
DIAGNOSTIC DATA: Chest x-ray images are reviewed. They show a left lung base opacity that is not traumatic. The abdomen shows a hiatal hernia and nonspecific bowel gas pattern.
ASSESSMENT:
1. Coffee-ground emesis.
2. Chronic renal insufficiency, mild exacerbation, likely due to gastrointestinal bleed.
3. Anemia.
4. Hypertension, uncontrolled.
PLAN:
1. Control hypertension.
2. Urine indices, renal osteodystrophy panel, iron studies.
3. Procrit to begin today.
4. The patient is hemodynamically stable, has been placed on proton pump inhibitors, and will likely need endoscopy soon.
